Isolated double gastric rupture as a result of blunt abdominal trauma.

To the Editor: Rupture of the stomach due to blunt trauma occurs infrequently and is associated with a high mortality. In reviews, the reported occurrence ranges from 0.02% to 1.7%.1,2,3,4,5,6 Only 67 cases have been reported in the literature since 1930. Yajka et al7 presented two cases and reviewed an additional 35 cases from the literature from 1930–1975. They reported a high rate of infectious complications and a mortality of 47%. Siemens and Fulton8 reported six cases and reviewed the cases presented by Yajka et al.7 They stressed the high mortality and morbidity associated with this injury. Semel and Fritelli have interpreted data in the literature as indicating an increase in the incidence of gastric rupture in the pediatric population.9

Recently, a child with double gastric rupture caused by blunt trauma was admitted to Mohayl General Hospital, Mohayl, in the Asir region. Knowing the infrequence of this sort of injury and especially of double rupture, we review of our experience with this injury. A 13-year-old boy who fell from his bicycle shortly after lunch (with a full stomach) was brought to our emergency department after about six hours after the accident. Clinical examination showed peritonitis so an emergency laparotomy was done after adequate resuscitation. On exploration about one and half liter of food and blood-mixed fluid was found. The stomach was ruptured at two places, in the anterior wall upper third and in the posterior wall upper third. The posterior wall was approached by opening the lesser sac. The upper abdominal muscles were also crushed, resulting in muscular haematoma. After copious irrigation, both stomach perforations were repaired in two layers. The necrosed abdominal muscle was debrided and the abdomen closed after placing tube drains.

Post-operatively, the patient’s fever continued and he developed bilateral pleural effusion with pneumonitis. The upper part of the wound also showed dehiscence. Due to continuous fever and toxicity he was re-explored on the 15th day and multiple intra abdominal abscesses were drained. The abdominal was closed with tension free sutures. The fever settled and his overall condition improved and he was discharged on the 25th day.

A history of a full stomach or recent meal is common with this injury, as in our case. A full stomach is important in the problem of gastric rupture because the empty stomach is much less likely to be ruptured by blunt force. When rupture occurs with a full stomach, massive peritoneal contamination results. The majority of patients either present in shock or develop hypotension shortly after arrival. Signs and symptoms of an acute abdomen are almost invariably present, but free intraperitoneal air on abdomen and chest films is seen only 16–66% of the time.3,8,9,10 Our patient showed no pneumo-peritoneum on X-ray.

The anterior wall of the stomach is the most common site of rupture. This distribution of rupture is related to the relatively fixed nature and momentum of a large volume of gastric contents.8 Our case had isolated double rupture of the stomach of both the anterior and posterior wall, with no other viscous injury. This is indeed uncommon and not often reported in the literature. This type of injury certainly shows the abruptness and severity of force applied over a full stomach. Interestingly, the healing capacity of the stomach is impressive in the face of such profound contamination and the formation of the intra-abdominal abscess. Only one suture line leak was mentioned by Franken and Barker11 and the patient survived. This tremendous healing quality of the stomach is doubtless related to its blood supply and strong seromuscular layer.

The mortality associated with traumatic gastric rupture has been reported to range from 0–66%.3,7,8,9 The majority of deaths occur mainly due to associated injuries. The majority of complications, however, are septic in nature and relate directly to massive intraperitoneal contamination. The most common complication is intra-abdominal abscess formation, which is often extensive, recurrent and very difficult to treat. As mentioned by Siemens and Fulton,8 intra-operative lavage, drainage of abscesses and systemic antibiotics are no guarantee against abscess formation, and an aggressive approach to re-operation and drainage of abscesses is the key to survival for these patients.